First Ketamine Patient – Opioids

09/05/2016 — Nancy Sajben MD

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You must get off opioids to get pain relief, even just to see where you are. I am continuing the conversation started September 2 because I am being attacked for saying get off opioids if you want to try something that may take away your pain. When you tire of pain and tire of monthly visits for opioids the next 30 years, try something better.

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I should have placed this case separately, not at end of note. Here’s the link to that post:

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Scroll toward the end of page to read it.

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Opioids cause pain. I’ve said that repeatedly on this site. They trigger pro-inflammatory cytokines in brain and spinal cord which causes more pain. See the links given on home page of this website and repeated below:

Please read my posts on May 26, 2009 on low dose naltrexone, dextromethorphan, ketamine and January 2011on neuroinflammation and the innate immune system in brain and spinal cord to understand some of the new concepts in medicine on which I base my approach. There is much overlap between pain systems and major depression systems, in medications and mechanisms in the brain. Quite often what works for pain will work for depression.

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I am continuing these comments because of continued attacks I am getting. Why attack me for suggesting pain may be treated with something other than opioids, that you must first taper off opiates, for saying opioids don’t work for CRPS?

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That is based on years of clinical experience since the turn of this century. What is your attack all about? If you like where you are at, stay there. America and the internet is full of attacks and rage — tearing so many people apart rather than building something, going forward, working together.

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It’s your choice! Cling all you want to what fails to help. Why attack me? and why expect me to post your attack on this educational site? People come to my office and presumably read those two links on the home page, copied above, and read many many case reports and many pages where I repeat: opioids cause pain. That opioid mechanism is validated research, not something I made up. And sure enough, people can get better after they taper off. But choose carefully what you replace it with.

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Some make an appointment and later are upset in the office when I say I am very mindful of CDC guidelines. If you are on some cocktail or some dose that some doctor has ramped up, do not expect other MD’s to agree with it. Why not stay with that MD? or have they lost their license? Yes, I do prescribe opioids. They may not be the dose you demand, and sadly you will be a patient for life if you take opioids.

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For these last 15 years, this new century, I am seeing patients do better and start to improve only after tapering off opioids. Have I not also defended opioids, railed against CDC opioid dictates? Opioids are all we have for some patients.

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One major obstacle to any alternative is that opioids make billions for pharma so why would pharma be induced to make something that actually relieves pain? I cannot even count how many opioids have been approved by FDA since the turn of this century,

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Stop the personal attacks. Free speech is American – go use it somewhere else. Morons and vicious cranks have taken over the web. Free us from vicious internet attacks that have changed web discourse into no discourse in this country, and now spread to polarized political opposition. Take no hostages. sheesh! Your personal experience is one I have seen thousands of for decades. Failures all. Lifelong use is the best you can hope for. So accept it and stop attacks. I cannot fight CDC. I tried for months to advise, but you don’t think they will stop at the current restrictions do you? Has your insurer already stopped paying for your opioid? That’s next. Why attack me?

We are all aiming for freedom. Freedom from pain, freedom in the body; plants are aiming for freedom, animals, social mores are striving for freedom, and we are all aiming for perfection. I hope the work I do continues to be a contribution towards that. It is amazing when it works. But people call to see me, and when I say they must come off opiates in order to do this exciting work, I am personally attacked. Rather than attacking the idea, I am attacked. We cannot move forward until you are ready to try. No one is forcing you to do anything. Stay where you are, find the doctor who will do what you want. Yes, the CDC is pushing everyone; the rules on dosing will get tighter, but they have nothing to offer in its place. Insurance stops paying for drugs that fall out of the CDC range. Congress is not needed to rope in the 80% of the opioids in the entire world that are prescribed in the US. Insurers like saving money on opioids that cost a fortune. $17,000 a month for one patient for one opioid, not counting the other one or two opioids and the many adjuvants these patients are on. See the incentive?

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I have time to report a small part of many years of clinical experience in seeing the amazing possibilities of complete freedom from pain — that occurs only after patients taper off opioids. I have posted case reports on these pages. Give up the attacks and fears. Go for better. No one is forcing you. You don’t have to give it a try. But there’s nothing to lose if you try. You could gain freedom.

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CDC is now getting an inkling, howbeit from a wrong direction, what happens after decades of NIH and congress fail to fund clinical pain research. Clinical research. Failing to ignore the essential discoveries of the innate immune system, how it regulates pain, glia and glial modulators. Medicine ignores science until pharma comes up with medications that modulate glia. But these medications already exist! We are ahead of the process. But it would help to invest in clinical trials on drugs that are glial modulators and a huge help to discover more.

Hello? any scientist or pharmaceutical company motivated to tear themselves away from the opioid epidemic — what other alternative is there, CDC? We have opioids. Can pharma open the curtain to their money making, and use all those lobbyists hired by pharma to influence politicians, FDA, CDC on better? Can’t government agencies think without being paid tens of millions by pharma lobbyists?

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Consciousness must be wider than opioids. It must include all the science on the innate immune system we have learned since glial research began 1991. Linda Watkins and her lab in Boulder Colorado and the worldwide collaborations form the most exciting thing that has happened to brain research in the last 100 years and it is so dynamic! Fast! It’s not like neurodegenerative diseases that take years or months to evolve before we see change. Glial inflammation is dynamic, instantly evolving and interacting with the brain and master control systems in the body. And the work likely will apply to slower degenerative conditions. Use medications that modulate inflammation in pain and depression to study more interventions.

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This inflammation is created by your innate immune system. We thought glia, these cells, were sort of like glue, holding neurons and structures together or something. Turns out glia are dynamic and we need to study them in vivo, in humans, using pain as an instant feedback mechanism. The rat studies are done. Dog studies done. Papers in place. Professor Watkins and Xalud Therapeutics need $20 million —$20,000,000 —to do the final clinical studies to submit to FDA for approval of the most exciting treatment I could imagine.

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Xalud has the anti-inflammatory cytokine IL-10 in the brain. You may become pain free for 3 months at a time with one injection into the spinal fluid, the CSF. IL-10 restores the anti-inflammatory balance in the brain and spinal cord, the CNS. Chronic pain is caused and/or perpetuated by a super abundance of pro-inflammatory cytokines. Also true of depression in rats, and schizophrenia in young teens who have early signs of schizophrenia.

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Pharmaceutical companies want to make billions in opioids. Fine, and let’s include something that actually helps too. I directly connected one owner of a pharmaceutical company. Small change for this multibillionaire. I failed: zero interest. He was completely invested in opioids for cancer pain. You know they want to seel to 50,000,000 with chronic pain, but FDA approved only for cancer pain. The money in fentanyl is making headlines because of street use. It’s all in the timing. Opioids had been riding a wave of highs, the pun is dead serious, epidemics of death spread like wildfire across the country. Now in the only clinic in North America where addicts can inject safely, they find 90% of the street heroin is contaminated with fentanyl. Fentanyl is 50 times stronger than heroin, your family members and friends are dying from heroin cut with fentanyl. No doubt that happened to Philip Seymour Hoffman, because fentanyl is easier to get on the street, surely it is famous for its high – all opioids are different, but addicts don’t know its power to kill. They don’t have a clue what the dose is. That’s the difference. Knowing its safety profile.

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All I am hoping is that now that fentanyl is riding a rapidly moving down the wave from its high after so many years, that one of the fentanyl making companies invest in glial modulators and hopefully in Xalud Therapeutics. Let’s get this important work off the ground. Professor Watkins has received awards from so many countries. She has been keynote speaker for so many annual medical and scientific meetings. Results are ignored by opioid companies and investors.

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We are ignoring the unharnessed power of the natural, dynamic system in the brain and how to quench the fire that some process has ignited. We can modulate and help to restore balance in the innate immune system. We need to understand so much more. We need glial imaging available only in Australia. All we have are opioids. I am angry. I want better for all.

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I am simply shocked at the evil of the status quo. The money in fentanyl. The failure of our president and congress to declare an emergency in treating pain and treating substance abuse. Give glial modulators the research it deserves. Stop with all the wars on cancer already. How about a war on cancer pain? We need tools in cancer pain because that applies to all. There is no such thing as cancer pain. Cancer can cause all the same types of pain that osteoarthritis can cause, only the added burden cancer can also kill.

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When I was teaching cancer pain management at MD Anderson Cancer Center, one of the best centers in the world, I saw how serious was our inability to relieve extreme pain when not even the surgical procedures touched pain, not cutting the spinal cord in half, not alcohol ablation of the lumbo-sacral plexus, not even slicing the small spot in the brain that would turn off the affect toward pain. The patient could feel it, but it did not affect them. They didn’t care about pain. Unfortunately, I hope I never see one of those again. The person was not there anymore. Their entire personality was missing and words fail to describe how awful that was. Obviously these procedures are done only in the last few weeks of life when death is certain and all other procedures failed including opioids.

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This country could fund pain research as part of the new war on cancer. Cancer pain, the one we all dread the most, is nerve pain. People with cancer have the same types of pain as anyone else, and nerve pain is the most difficult to treat. It has been astonishing for me to literally see intractable nerve pain go into remission. Why for Pete’s sake do I want to waste more of the past 42 years in medicine giving yet another page to someone angry about opioids and attacking me for comments on these pages?

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Gene Wilder once said about why he was so against the acting business, he said: “I like the acting, I don’t like the business.” Pharma is a money making business. Business ethics are not the same as medical ethics. Why should pharma do anything but focus on money making opioids? They will if CDC cranks down their money making machine even more. And they will, only because they will see it has nothing to do with addicts killing themselves. That’s where we are back to the fentanyl. Heroin laced with fentanyl that’s 50 times stronger than heroin. More and more middle class people will see someone in their family dead from fentanyl on the streets. Kids in grade school passing pills of fentanyl they got on Amazon.

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Chronic pain, especially nerve pain, is most difficult to treat. It is never all about medication. Never. You must also learn tools you can use. Even if you pain goes to zero, are you deconditioned? I am certain you’ve got muscles involved and they need help too. You may easily be thinking the pain from those muscle points are nerve pain. Nope. Muscle stuff must be addressed in the language that muscles speak. They don’t speak medicine language.

Work with a psychologist on CBT or DBT. A pain psychologist is not needed to learn tools to make your mind strong. We must all use those tools. We must all be strong. No one can afford to fall apart emotionally because we know that makes pain worse. Learn the tools to use or else pain. There is no surgery, no pill, no Valium or Xanax or Ativan that can make you strong — no crutch. The dark bunny hole will always be there. Nietche’s abyss – we are always walking over the abyss. Do not look down. Look up.

Once we know how to cope, we have tools we can use at any time. Same with muscles that have been inactive for years. Tools we all learn. The entire family together can be taught what it takes for physical therapy. We cannot help all people. Some in pain need family help to bathe and dress and remember home exercises.

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For CRPS especially, we want to prevent spread, mirroring, appearing in the other limb and distant areas. I like to think of treatment like a football game. You’ve failed everything known, that makes it potentially harder. Spinal cord stimulators, nerve blocks, every known pill and high dose opioids. But you’ve got to win this game. You have one guy running down the field with a football, how many guys are you going to send after him? What if 3 or 4 guys only partially help? Add that up and you may have extra 30 or 40% relief. Hit pain hard, use selectively chosen glial modulators and others with mechanisms on these pathways, get pain to zero – or give it the best chance to get it near zero pain. That’s the first goal.

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Nothing is perfect. Nothing in medicine is perfect. It is still an art, not a science. But it is a gift to be able to use these tools that I’ve selected to use together the last 15 years. It’s thrilling to see the science come out explaining even more the power of the innate immune system, the glia.

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Had the practice of medicine evolved, we’d have worked with, not against, the timing of the circadian clock in these cells to prevent postoperative chronic pain, or minimize sending the inflammation into overdrive. That is not happening. Medicine is not tracking with the science. Opioids damage the balance of inflammation in a system already exploding with pain. It would be a miracle if providers and patients ever stop reaching for opioids first. Do they even understand they are doing the opposite of relieving pain, or care that better choices exist? Perhaps, but it would take a multi-zillion dollar study.

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Pain management is only taught in 3% of medical schools. It loses money. Procedures make money. This is not about procedures. It’s about thinking and using proven mechanisms. Ask any MD and they’ve never heard of glial modulators. We all rely instead on Pharma and medications approved by FDA to educate on all treatment – that goes for NIH and all medical schools and hospitals too. They teach opioids plus 1960’s pain management. When CDC takes away the opioids, we are treating pain using 1960’s methods plus gabapentin, Lyrica, Cymbalta. And what % of patients did these new drugs help? one third? Half? No wonder 50 million people have chronic pain. We have 5 different short acting fentanyl products alone. And why is Amazon selling fentanyl when every city and country in the U.S. has people dying from it. Horse and dog fentanyl is same as human fentanyl. Some people think ketamine is a horse tranquilizer, as if it’s shocking to them to think horses and humans would respond differently. Give enough of a sedative, you go into a coma and then you can die. Use medication only under medical supervision.

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4 Responses to “First Ketamine Patient – Opioids”

Thank you Doctor – I only wish my MD would put me ketamine. I’m so depressed. The CRPS has hurt my brain so badly. They just don’t understand the benefits of K. They would rather us be on cocktails. I don’t wish to be on any big pharma meds. I have tried to explain it to her- anyway you are fantastic- keep up the great work

I have chronic pain and was on daily opioids for about 4 years. I felt like I couldn’t survive without them. That’s one of the problems with opioids. It’s impossible to take them daily and not become addicted to them. I always took them as prescribed, etc. The opioids themselves convince you that you cannot live without them. I got off of them about a year ago and it was the best decision I ever made. I still have pain, everyday. I just started LDN a couple of weeks ago and am hoping it works for me. I have never regretted getting off of opioids. I think everything you are saying is true and relevant. But when I was taking opioids I would have been threatened by what you are saying. A lot of the hate you are receiving is the opioids talking.